Chorioamnionitis: its association with pregnancy outcome and microbial infection

In a study of 33 cases of perinatal death, chorioamnionitis was observed in 57.6% compared with 5% of 20 control cases (p less than 0.001) and in 70.8% of cases with no morphologic cause compared with 22.2% of cases with a defined cause of death (p less than 0.01). Chorioamnionitis was significantly associated with previous gestations (p less than 0.01), prolonged rupture of the membranes (p less than 0.001), prematurity (20 to 27 weeks' gestation) (p less than 0.001), and low birth weight (less than or equal to 1000 gm) (p less than 0.001) but not with elevated maternal white blood cell count or pyrexia. Overall, in patients with chorioamnionitis, the perinatal death rate was higher (p less than 0.01); more stillbirths occurred compared with early neonatal deaths (p less than 0.05), and there was a higher incidence of deaths with no defined cause (p less than 0.01) compared with cases without chorioamnionitis. Ureaplasma urealyticum or pathogenic bacteria were isolated more frequently from villous tissue of placentas from cases with chorioamnionitis (p less than 0.01) but not Mycoplasma hominis, Chlamydia trachomatis, or viruses. Furthermore, there was a higher prevalence of both elevated fetal antibody titer to U. urealyticum (p less than 0.025) and fetal titer fourfold above maternal titers (p less than 0.05) in cases with chorioamnionitis. The antibody responses and presence of microorganisms suggest that chorioamnionitis is associated with intrauterine infection and an associated increase in perinatal morbidity and mortality.     

Value of measuring bone density serial changes on a picture archiving and communication systems (PACS) monitor in distraction osteogenesis

Serial changes of bone density in 26 femora and 22 tibiae that underwent leg lengthening by distraction osteogenesis were investigated by measuring the pixel value shown on a picture archiving and communication systems (PACS) monitor. The pixel value of the original cortex did not change significantly until the external fixator was removed. The pixel value of the distraction sites did not change significantly for the first 5-6 weeks/cm, but rapidly increased after 7 weeks/cm in the femur and tibia, then slowly increased after 8 weeks/cm. The serial changes of the pixel value of the distracted bone showed a sigmoid curve, rather than a straight increasing line. The relative pixel values of the lengthening sites were >95% in three of the four cortices at external fixator removal. Thus, the pixel value of PACS is a rapid and easy method for the detection of bone density changes in distraction osteogenesis.     

Cutoff score on the apathy evaluation scale in subjects with traumatic brain injury

This cross-sectional study was designed to determine a cutoff score on the Apathy Evaluation Scale (AES) that predicts a clinician's designation of a subject with TBI as apathetic or not. Forty-five outpatients with TBI completed the AES-S, and 37 family members, friends, or significant others filled out the AES-I. Three clinicians prospectively gave their impressions of the presence or absence of apathy and retrospectively chose the degree of apathy on a 7-point subjective rating scale. The data was analysed by logistic regression and Receiver Operating Characteristic (ROC) curve. Sensitivity and specificity were calculated. No cutoff score on the AES-S or AES-I was found to have reasonable sensitivity and specificity with respect to the ability to predict the clinician's designation of a subject as apathetic. The AES requires further study if it is to be used to measure apathy following TBI.     

Elevation of arterial potassium during acute systemic hypoxia is abolished by alkalosis

BACKGROUND: Small elevations in plasma potassium evoke vasodilation in the peripheral circulation. Systemic hypoxia elevates arterial potassium and also modifies arterial pH. AIMS: We examined the interaction between pH and potassium in blood during systemic hypoxia and the effect of pH on the uptake/release of potassium in the peripheral tissues. METHODS: Anesthetized dogs were ventilated with air plus oxygen for normoxia or air plus nitrogen for hypoxia. Some animals received intravenous sodium bicarbonate to elevate pH by 0.1 units. Arterial plasma potassium concentration was measured in normoxia and hypoxia. A rat gracilis muscle was perfused with normoxic Krebs buffer and the potassium content of the venous outflow was compared during perfusion at pH 7.4, 6.8, or 7.8. RESULTS: In dogs with an arterial pH of 7.40-7.45, systemic hypoxia elevated the arterial potassium by 1 mmol/L. An arterial pH of 7.55 did not alter the basal potassium concentration, but it abolished the hypoxia-induced increase. In rat muscle, reduction of the perfusate pH from 7.4 to 6.8 reduced arterial perfusion pressure from 8.73 to 7.32 kPa and venous potassium from 6.6 to 5.2 mM. Elevation of perfusate pH to 7.8 decreased the arterial perfusion pressure from 8.44 to 6.95 kPa but did not affect venous potassium. CONCLUSIONS: The hypoxia-induced elevation of arterial potassium is abolished by increasing the pH to 7.55. This is not due to enhanced potassium uptake into peripheral tissues at high pH. Red blood cells are suggested as the most likely source of the potassium released in hypoxia.     

Mycophenolic acid concentrations in long-term heart transplant patients: relationship with calcineurin antagonists and acute rejection

BACKGROUND: When used in conjunction with steroids and cyclosporin, mycophenolate mofetil (MMF) has been shown to significantly reduce mortality and incidence of rejection in the first year after heart transplantation. It also appears that in this early post-transplantation period, the monitoring of immunosuppressive therapies may be warranted. The current study was undertaken to determine if such monitoring is still useful more than 1 yr after heart transplantation. METHODS: Twenty-six patients who had survived the first year after orthotopic heart transplantation and had been on MMF therapy for more than 3 months were prospectively followed. At the time of their routine endomyocardial biopsy blood samples were taken to monitor immunosuppressive therapy. Most patients had two samples taken, on average 109 d apart. RESULTS: There were 22 episodes of asymptomatic rejection documented on a total of 48 biopsies. Of these, only two were of ISHLT (International Society for Heart and Lung Transplantation) grade 3A the remainder being of ISHLT grades 1 or 2. There was no relation between immunosuppressive regimen (tacrolimus and MMF or cyclosporin and MMF) and rejection. There was no relation between monitored immunosuppressive levels and rejection. Patients with the combination of MMF and tacrolimus had significantly higher plasma mycophenolic acid levels despite significantly lower daily MMF dose. CONCLUSION: There does not appear to be a benefit in continued monitoring of plasma mycophenolic acid levels beyond the first year of heart transplantation. There were significant differences in plasma mycophenolic acid levels depending on the type of calcineurin inhibitor concomitantly used.     

Preoperative endoscopic sphincterotomy in the treatment of patients with cholecystocholedocholithiasis

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) prior to laparoscopic cholecystectomy (LC) are the most common methods for the diagnosis and treatment of patients with cholecystocholedocholithiasis. We evaluated the selection criteria for preoperative ERCP examination and the results of endoscopic-laparoscopic treatment of patients with choledocholithiasis. Between January 1993 and December 1998, 1630 patients with symptomatic cholelithiasis were admitted for surgical intervention. Preoperative ERCP was performed in 247 patients according to the selection criteria. The criteria to perform ERCP were dilated common bile duct (CBD; more than 8 mm), abnormal serum liver test results, and a recent history of pancreatitis. Endoscopic sphincterotomy (ES) was performed if CBD stones were found during the procedure. LC was then carried out within 3 days after ES. Of the 247 patients selected for preoperative ERCP, CBD stones were confirmed in 146 patients (59.1%). ES was successful in 141 patients, and stone clearance was achieved in 133 patients, resulting in a 94.3% success rate. Eight patients (5.5%) had complications after endoscopic intervention, all of which resolved uneventfully. Open operative procedures were carried out in a total of 31 patients. Overall, 115 patients were successfully treated by this endoscopic laparoscopic sequence. The length of hospital stay in these groups was significantly lower than that for patients in whom an open method was employed. Preoperative ES combined with LC is a safe and effective therapy for cholecystocholedocholithiasis, and the criteria that we used for the selection of patients seem to be appropriate. Received: July 4, 2000 / Accepted: October 12, 2000     

Rapid and durable recovery of visual function in a patient with von hippel-lindau syndrome after systemic therapy with vascular endothelial growth factor receptor inhibitor su5416

PURPOSE: To present a case of rapid and durable recovery of visual function in a patient with von Hippel-Lindau syndrome and optic nerve head hemangioblastoma after systemic treatment with the vascular endothelial growth factor (VEGF) receptor inhibitor SU5416. DESIGN: Interventional case report. METHODS: Visual function parameters, including visual acuity, automated visual field, and contrast sensitivity, were evaluated using standardized methods repeatedly over a 15-month period. Fundus photographs and fluorescein angiograms were also obtained. Central nervous system lesions were monitored by computed tomography (CT) and magnetic resonance imaging (MRI) scans. Treatment involved the systemic administration of the VEGF receptor inhibitor SU5416. MAIN OUTCOME MEASURES: Clinical presentation, visual acuity using Early Treatment Diabetic Retinopathy Study protocol, Humphrey automated perimetry, (Zeiss Humphrey Systems, Dublin, CA) Vistech contrast sensitivity (Vistech Consultants Inc., Dayton, OH) Farnsworth (Farnsworth-Munsell Color Services, New Windsor, NY) dichotomous panel D-15, retinal photography, fluorescein angiography, and CT and MRI scans. RESULTS: Within 4 weeks of therapy, visual acuity had improved from 20/32(-2) to 20/16(-1), the visual field had expanded from being circumferentially constricted to within 8 degrees of fixation to normal, and contrast sensitivity improved in all but the lowest spatial frequency (1.5 cycles/degree). No change was observed in lesion size by fundus photography. Improvement has been maintained over 18 months with intermittent SU5416 therapy. CONCLUSIONS: We report rapid, extensive, and durable recovery of visual function after systemic administration of the VEGF receptor inhibitor SU5416 to a patient with VHL syndrome and optic nerve head hemangioblastoma. These findings suggest that continued evaluation of VEGF inhibitors for ocular neovascular disorders is warranted.     

Environmental influences on brain neurotrophins in rats

Environmental factors can have profound influences on the brain. Enriching environments with physical, social and sensory stimuli are now established to be beneficial to brain development and ageing. A multitude of responses from cellular and molecular mechanisms to macroscopic changes in neural morphology and neurogenesis have been considered in the context for evidences that environmental inputs can regulate brain plasticity in the rat at all stages of life. Data from our laboratory have revealed that enriched environment increased nerve growth factor (NGF) gene expression and protein levels in the hippocampus, and this may contribute to events underlying environmentally induced neural plasticity. Because neurotrophic factors are essential for neural development and survival, they are likely to be involved in the cerebral consequences modified by enriched experiences.     

Insulin aspart: a review of its use in the management of type 1 and 2 diabetes mellitus

Insulin aspart, a rapid-acting human insulin analogue, provides more rapid absorption than regular human insulin after subcutaneous administration. In most randomised, nonblind clinical trials in patients with type 1 diabetes mellitus, insulin aspart administered immediately before meals resulted in significantly lower mean glycosylated haemoglobin A(1c ) (HbA(1c)) levels than regular human insulin (usually administered 30 minutes before a meal). Insulin aspart also significantly improved postprandial glycaemic control compared with regular human insulin. The efficacy of insulin aspart was similar to that of insulin lispro when administered to patients with type 1 diabetes mellitus via continuous subcutaneous infusion in a randomised, nonblind trial. Preliminary data from randomised, nonblind trials suggest insulin aspart had a trend towards lower HbA(1c) levels compared with regular human insulin in patients with type 2 diabetes mellitus. Biphasic insulin aspart [30% soluble (rapid-acting) and 70% protamine-bound insulin aspart (BIAsp30)] generally provided significantly better postprandial glucose control than a similar mixture of biphasic regular human insulin (BHI30) in a randomised, nonblind trial in patients with type 1 or 2 diabetes mellitus. However, the long-term efficacy of BIAsp30 was similar to that of BHI30 after 2 years in a randomised, nonblind trial in patients with type 2 diabetes mellitus. Patients with type 1 or 2 diabetes mellitus reported greater treatment satisfaction with insulin aspart or BIAsp30 than with regular human insulin or BHI30. The overall incidence of hypoglycaemia with insulin aspart was lower than, or similar to, that of regular human insulin. Moreover, insulin aspart tended to be associated with a lower occurrence of nocturnal hypoglycaemia and severe hypoglycaemic events than regular human insulin. CONCLUSION: The standard preparation of insulin aspart has the potential to better mimic the physiological response to meals than regular human insulin. Insulin aspart when combined with a suitable basal insulin improved overall glycaemic control and led to a similar or lower number of hypoglycaemic episodes compared with a similar regular human insulin regimen. Insulin aspart was generally as effective and well tolerated as insulin lispro when administered by continuous subcutaneous infusion in a single comparative trial. The efficacy of biphasic insulin aspart has been documented in a small number of trials. Both insulin aspart and biphasic insulin aspart provide for flexible and convenient administration. Insulin aspart is now well established as an effective and convenient means of providing glycaemic control which offers clinical and practical advantages over regular human insulin.